Complementary and alternative medicine (CAM) therapies—which include many natural products—are widely used alone or in combination with psychotropic drugs to treat or self-treat mental illness. It has been estimated that up to half of all individuals with a diagnosed mood disorder use 1 or more CAMs.1,2 A significant percentage of this population combines conventional pharmacological treatments with CAMs.3

In bipolar disorder, however, there is relatively little evidence for the safety and efficacy of most CAM or integrative treatments.4,5 A recent survey of older patients with a diagnosed major depressive disorder (n = 50) or bipolar disorder (n = 50) found that 44% of those with bipolar disorder use herbal and other natural products compared with only 16% of those who were depressed.6 Another significant finding of the survey was that up to 20% of older patients with a mood disorder preferred to use herbal or other natural products over prescription medications, and that more than 40% of older adults believed that natural products were regulated by the FDA for treatment of depressed mood and bipolar disorder. The majority of older adults with a diagnosis of any mood disorder (64%) had not discussed use of herbals or other natural products with their physicians.

I briefly review the limitations of conventional pharmacological therapies in this article. My goal is to identify factors that lead increasing numbers of patients with bipolar disorder to use CAMs alone or in combination with conventional pharmacotherapy (ie, as integrative treatments). I then examine the evidence base for select CAM and integrative modalities currently used to treat or self-treat bipolar disorder. Finally, I offer provisional guidelines for the safe, judicious use of select CAM therapies as adjuvants in both phases of bipolar disorder.

Where study findings permitted statistical analysis, effect sizes are presented as Cohen’s d by finding the difference between the intervention and placebo scores on the scale used (eg, Hamilton Rating Scale for Depression [HAM-D], Young Mania Rating Scale [YMRS]) and dividing this by the pooled standard deviation at baseline.7

Limitations of conventional treatment approaches

To provide the best clinical advice to patients with bipolar disorder about the range of available treatment choices, psychiatrists and other mental health professionals should be knowledgeable about the evidence that supports conventional pharmacological treatments as well as promising CAM and integrative treatment strategies. While conventional pharmacological treatment is necessary for patients in the acute phase of bipolar illness, medications alone do not make up an adequate maintenance strategy for stable bipolar patients. For example, regular exercise, adequate sleep, good nutrition, a strong social support network, and a predictable low-stress environment are known to significantly reduce relapse risk in bipolar patients who are being treated with mood stabilizers.8,9 Integrative mental health care embraces the perspective that tailoring an individualized treatment plan to each patient’s unique history, symptoms, preferences, and financial constraints increases the patient’s motivation to stay in treatment, which improves adherence and results in better outcomes.

Widely prescribed pharmacological treatments of both the depressive and manic phases of bipolar disorder have a mixed record of success because of their limited effectiveness and high rates of discontinuation.10 One study showed that fewer than half of the patients who were treated with a conventional mood stabilizer or other psychotropic medications after an initial manic episode reported sustained control of their symptoms.11 Furthermore, as many as half of all patients with bipolar disorder who take maintenance mood stabilizers do not experience good control of their symptoms or they refuse to take medications, and approximately half eventually discontinue their medications because of adverse effects that include tremor, weight gain, and elevated liver enzyme levels.12

A significant percentage of patients with bipolar disorder rely on maintenance antidepressant therapy to control depressive mood swings, which significantly increase the risk of mania. Commonly prescribed pharmacological regimens used to treat bipolar disorder combine mood stabilizers with antidepressants or atypical antipsychotics; however, a systematic review found only modest improvements in outcomes when such combination therapy was used.13

The limited effectiveness and safety issues associated with conventional psychotropics in the management of bipolar disorder have resulted in high relapse rates in individuals taking mood stabilizers and other psychotropic medications, with associated impairment in social, academic, and occupational functioning, and increased risk of suicide.14 These issues underscore the urgent need to identify more effective, better-tolerated treatments for bipolar disorder and invite rigorous and open-minded consideration of emerging research findings for promising CAM and integrative treatments.

Table 1 summarizes significant findings and comments on unresolved research and treatment issues for the natural products reviewed in this article.

Omega-3 essential fatty acids (v-3s)

Placebo-controlled trials have evaluated v-3s in bipolar disorder as both a monotherapy and an adjuvant to mood stabilizers. In an early controlled trial of 44 patients with stable bipolar disorder who were treated with eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) (9.6 g/d) in combination with mood stabilizers, significant improvements were seen in depressed mood on the HAM-D (d = 1.40); however, changes in symptoms of mania by the YMRS were not significant.15